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Service Delivery Innovation Profile

Home Visit for All Newborns To Assess Risk of Child Maltreatment Improves Parenting Skills, Reduces Medical Emergencies, and Generates Positive Return on Investment


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Snapshot

Summary

To promote healthy infant development and reduce child maltreatment and abuse, Durham Connects offers all families with newborns in Durham County, NC, the opportunity for a nurse to come to the home to perform a comprehensive assessment of risk factors and provide education and support tailored to the families' risks and needs, including connections to community-based resources. The program has enhanced the ability to identify at-risk families; improved connections to community resources, parenting skills, and the safety and quality of the home environment; and significantly reduced infant medical emergencies. In its first year, the program generated an estimated $3 in cost savings for every dollar invested.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized, controlled trial that compared various outcomes in participating families with similar families not enrolled in the program, with randomization achieved by assigning families based on whether the child was born on an even or odd date. Additional evidence consists of post-implementation reports from enrolled parents on their satisfaction with the program and estimates of the program’s return on investment and cost-savings potential based on results from the randomized trial.
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Developing Organizations

Center for Child & Family Health; Center for Child and Family Policy at Duke University; Durham County Department of Public Health
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Use By Other Organizations

As noted, plans are in place to use the same model in four other North Carolina counties. In addition, two counties in other States have similar programs, including Los Angeles County’s First 5 LA program (http://www.first5la.org), and Kent County, Ohio’s Welcome Home Baby program (http://www.firststepskent.org/programs/welcome-home-baby). The State of Massachusetts plans to launch a similar program in a few counties and then roll it out across the State over time.

Date First Implemented

2008
Pilot testing of an initial version of the program began in 2008, after which some minor modifications occurred. The current program launched beginning with an 18-month randomized controlled trial on July 1, 2009.begin ppxml

Patient Population

The program serves all families of newborns in Durham County. During the initial trial, European Americans accounted for 40 percent of participants and African Americans for 37 percent, with the remainder being from other racial and ethnic groups. Most (62 percent) had no health insurance or were enrolled in Medicaid at birth.Age > Newborn (0-1 month)end pp

Problem Addressed

Maltreatment of children occurs frequently and can lead to medical, psychological, and developmental problems, and in some cases death. Home visits shortly after a child’s birth can help prevent maltreatment by connecting families to needed resources. However, where they exist, home visit programs generally use broad demographic factors to identify at-risk families and then focus all resources on those identified. This approach creates two problems: first, there may be a stigma associated with participating, since by definition all participants are deemed at risk. Second, the vast majority of families in the community receive no help, including many with risk factors that can only be identified through a thorough assessment.
  • A common occurrence: Nearly 800,000 children (or roughly 10.6 out of every 1,000 children) are maltreated each year in the United States.1 In North Carolina in 2008–2009, almost 68,000 reports came to child protective services, a rate of roughly 30 reports per 1,000 children. Overall, 7.4 percent of these cases were substantiated as involving abuse, neglect, or dependency, while another 35 percent resulted in services being provided or offered.2 Before implementation of this program, rates of child maltreatment in Durham County were well above both State and national averages.
  • Leading to multiple health-related problems, high costs: Maltreatment of children can lead to short- and long-term problems, including physical injuries, psychological and developmental problems, learning and conduct disorders, and occasionally death.3,4 In North Carolina in 2007, 25 homicides occurred as a result of child abuse and 139 child deaths were attributed to neglect.5 The cost of child maltreatment can be quite high; one study estimates $95 billion in annual costs in the United States, including expenses associated with medical and mental health treatment, lost productivity, and crime.6
  • Shortcomings with existing programs: Home visits from nurses have been shown to connect families with newborns to needed resources, have a positive impact on parenting behavior, and reduce the need for emergency medical care. However, where they exist, such programs typically serve families identified as being at risk based on broad demographic risk factors (e.g., first-time, low-income mothers). This approach may create a stigma associated with participating. In addition, while the families served by the program tend to receive extensive levels of support, many other families that may also have risk factors receive no support at all.7,8

What They Did

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Description of the Innovative Activity

To reduce child maltreatment and abuse, Durham Connects offers all families with newborns in Durham County the opportunity for a nurse to come to the home to perform a comprehensive assessment and provide education and support tailored to the families' risks and needs, including connecting them to community-based resources. Key program elements are outlined below:
  • In-hospital offer to all families of newborns: The program serves all families with newborns in Durham County, NC. Each day, the program receives a list of all births that occurred the previous day in the two hospitals that deliver babies in the county. Also each day, nurses visit both hospitals to briefly meet with eligible families. During this roughly 5-minute conversation, the nurse explains the benefits of the program, including its ability to provide education and support and connect families to needed social and community-based services. The nurse also gets a sense for the kinds of issues and concerns the mother may have, such as whether they are anxious or concerned about breastfeeding.
  • Inhospital support, enrollment, scheduling of home visit: As part of the same inhospital visit, the nurse enrolls those who are interested, secures up-to-date contact information, gets approval to speak with the mother’s physician, and sets up the date and time for the initial home visit, typically about 3 weeks (although in some cases up to 12 weeks) after the baby is born. During the randomized trial, just over 80 percent of those offered the program enrolled in it. All information for enrollees is entered into the program’s electronic medical record (EMR) system.8
  • Comprehensive home visit to assess, address risk factors: A public health nurse conducts the home visit, which typically takes 1 to 3 hours. Whenever possible and appropriate, the program assigns a nurse who is a good fit with any concerns or issues identified during the inhospital visit. For example, if the mother expresses concerns about breastfeeding, efforts will be made to send a nurse who is also a certified lactation consultant. The visit itself consists of a comprehensive assessment of the family’s strengths and risk factors for maltreatment, assignment of a risk score, and provision of education and support (including referrals to needed community-based resources) to help address identified risks, as outlined below:
    • In-depth assessment: Trained nurses use the Family Support Matrix9 to assess health and psychosocial risks across 4 domains that collectively include 12 factors shown to be linked with the risk of child maltreatment. They collect this information in a nondirective manner through multiple sources, including interviews, observations, and questionnaires. All information is entered into the EMR database system.
      • Support for health care: This domain assesses parent health, infant health and safety, and the family’s health care plans.
      • Support for parenting/child care: This domain assesses plans related to child care, the parent-child relationship, and how the parent views and manages infant crying.
      • Support for a safe home: This domain evaluates the availability of household and material support (e.g., adequate financial resources, use of Medicaid and other public programs), history and potential for family and community violence, and history of parenting problems and child maltreatment.
      • Parent mental health and well-being: This domain includes an assessment of the parent’s mental health (e.g., level of depression and anxiety), past or current substance abuse, and the degree of social and emotional support available.
    • Assignment of risk level: Nurses score each of the 12 factors on a 4-point scale. The overall family risk level is determined by the risk factor with the highest score as outlined below.
      • Low risk: A score of 1 indicates low risk, meaning the family functions well with no need for intervention. In the initial trial (which covered all 4,777 births in Durham County over an 18-month period), only 6 percent of families had no identified risk factors.7
      • Moderate risk: A score of 2 indicates moderate risk, meaning the family has some risks that can be resolved adequately through nurse-led interventions in the home. In the aforementioned trial, just under half (49 percent) of families had an overall moderate risk, meaning the family had at least one score of 2 but no scores of 3 or higher.7
      • High risk: A score of 3 indicates high risk, meaning the family has substantial risk factors that warrant connection to one or more community resources that can provide long-term support. During the trial, 44 percent of families had at least one risk factor with a score of 3. These risks were most frequently related to the health care and household safety (including domestic violence) domains.7
      • Imminent risk: While rare, a score of 4 indicates an imminent health or material living risk that requires an immediate emergency intervention. During the trial, only 1 percent of families had any risk factors scored as a 4.7
    • Education and support based on identified needs: Nurses provide education and other support tailored to the level and nature of the risks faced by families, including referrals to needed community-based services, as outlined below:
      • Tailored education and material support: Nurses have been trained to provide “teachings” or direct interventions to all families regardless of risk or needs. Teachings provide evidence-based health and child care information, as well as parenting education on subjects about which Durham Connects nurses are knowledgeable, including breastfeeding, infant nutrition, immunizations, meeting infants’ physical and emotional needs, child development, infant and child safety, good parenting, postpartum recovery, physical complications of labor and delivery, and postpartum depression. During the initial trial, nurses implemented an average of just under 14 direct interventions per family, with the most common being related to mental health (given to 55 percent of families), household supports (46 percent), infant health (40 percent), and maternal well-being (37 percent). Material support, including diapers, thermometers, age-appropriate books, and other items, are also provided to families who need them.7
      • Referrals for needed medical and community-based resources: During the visit, nurses use an electronic database (known as Agency Finder) that includes up-to-date information on several hundred local community-based agencies. The database includes detailed information on agency offerings so as to promote the best possible match. For example, for new mothers who speak Spanish, nurses can identify agencies with Spanish-speaking staff. Whenever possible, the nurse attempts to contact the relevant agency or agencies during the home visit to set up the appointment(s), and makes sure the family will have transportation available to get there. 
  • Followup calls and visits: As necessary, nurses make additional home visits and telephone calls to families during the first few weeks after the initial home visit. Typically this type of followup occurs when the nurse has identified or suspects more serious risks. For example, a nurse may suspect domestic violence but not be in a position to assess the level of risk during the initial visit because the father is present. For other high-risk cases, the nurse may come back to the home to offer additional interventions (e.g., breastfeeding support), bring needed supplies (e.g., food, clothing), and ensure connection to needed services.
  • Case closeout: Once followup visits or calls have been completed, the nurse closes out the case, typically within 1 to 2 weeks of the initial home visit.
  • Telephone check-in to monitor connections: Roughly a month after the case has been closed, the nurse calls the family to make sure that any connections to community agencies have been made and maintained. This information is entered into the Agency Finder database, allowing program leaders to identify agencies that may not consistently be connecting with those referred to them and to identify and address any gaps in available resources in the community.

Context of the Innovation

Established on July 1, 1999, at Duke University, the Center for Child and Family Policy brings together faculty, researchers, staff, and students in an effort to develop solutions to important problems affecting children and families. The impetus for Durham Connects dates back to the 2001–2002 period, when Kenneth A. Dodge, PhD, director of the center and a professor at Duke University, began discussions with the Duke Endowment about opportunities to reduce rates of child maltreatment and abuse in Durham County, which had historically been higher than State and national averages. Through these discussions, the Duke Endowment launched the Durham Family Initiative (DFI), a 10-year project focused on significantly reducing child maltreatment and abuse throughout Durham County. The Duke Endowment partnered with the Center for Child and Family Policy, the Center for Child & Family Health (a Durham-based collaboration of Duke University, the University of North Carolina at Chapel Hill, and North Carolina Central University), and the Durham County Department of Public Health on this initiative.

During its early years, DFI launched multiple programs aimed at reducing child maltreatment and abuse, with most programs focused on at-risk families and neighborhoods. While these programs had some success, DFI leaders had a general sense that the decline in maltreatment and abuse was not as great as it could be, and also had no way to know whether DFI initiatives accounted for those declines that had occurred. DFI leaders came to believe that significant success in addressing maltreatment and abuse could not be achieved unless programs targeted the entire population.

Consequently, beginning around 2006, DFI leaders began exploring the potential to create and rigorously evaluate a population-based program to reduce child maltreatment throughout Durham County. Recognizing that this universal approach could easily become quite expensive and resource-intensive, their goal was to create a relatively brief, affordable intervention grounded in developmental science theory, and then fully describe it in a manual for replication in other communities.

Did It Work?

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Results

The program has enhanced the ability to identify at-risk families; improved connections to community resources, parenting skills, and the safety and quality of the home environment; and significantly reduced infant medical emergencies. It generates an estimated $3 in cost savings for every dollar invested.
  • Better able to identify at-risk families: Compared with the traditional approach of assessing risk based only on broad demographic factors, the approach used by Durham Connects had 39 percent lower error rates with respect to predicting the need for future infant emergency medical services.8
  • More community connections: In a randomized trial involving all 4,777 births in Durham County between July 1, 2009, and December 31, 2010, telephone contacts conducted 4 weeks after cases had been closed indicated that enrolled families made connections to 61 percent of the community resources proposed by the nurse, including 39 percent where the services had already been received. Six months after the program ended, families eligible for Durham Connects reported accessing 16 percent more community services during the previous 3 months than those in the control group.7
  • Better parenting: Six months after their participation in the program ended, families served by Durham Connects reported more positive parenting behaviors (e.g., hugging and reading to their children) than those in the control group, and in-home observers rated the quality of parenting (defined as sensitivity to and acceptance of the infant) to be higher among enrolled mothers than those in the control group. Participating and control-group families reported no differences in negative parenting behaviors, knowledge of infant development, or sense of parenting competence.8
  • Better choices related to child care: While the likelihood of using out-of-home child care did not vary across the groups, Durham Connects enrollees tended to place their children in higher quality care than did control-group families (4.61 versus 3.98 on the State’s 5-star rating system).8
  • Less anxious mothers: Mothers participating in the program were 28-percent less likely to be rated by nurses as having clinical anxiety than mothers in the control group. No difference existed between the groups with respect to observed depression or substance use.7
  • Better, safer home environment: Six months after the program ended, in-home observers rated the home environment as better for families enrolled in Durham Connects than for those in the control group, including being safer and having more or better books, toys, and learning materials.8
  • Significantly fewer infant medical emergencies: During the 6 months after the program ended, a review of hospital records showed that families enrolled in Durham Connects had 59 percent fewer emergency medical care episodes, including 18-percent fewer emergency department visits and 85 percent fewer overnight hospital stays than did infants of families in the control group.7 A followup review of hospital records when infants reached 12 months of age showed that families assigned to Durham Connects had 50 percent fewer medical care episodes than did those in the control group, with these reductions occurring in all subgroups of families studied.10
  • Positive return on investment, substantial cost savings: Program leaders estimate that Durham Connects saves just over $3 for every dollar invested, with the savings primarily generated from the reductions in the costs of emergency medical care during the first 6 months of life. Extrapolating these savings across the entire county (which averages 3,187 births a year), Durham Connects has the potential to yield net savings of approximately $4.5 million ($6.7 million in cost savings less $2.2 million for program-related costs).8
  • High levels of participant satisfaction: The vast majority of participating families found major components of the program to be helpful, including the materials provided by the nurse (99 percent), discussions with the nurse about the mother’s needs (98 percent), and nurse teachings (95 percent). Overall, 99 percent of mothers served by the program indicated they would recommend it to another new mother.7

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized, controlled trial that compared various outcomes in participating families with similar families not enrolled in the program, with randomization achieved by assigning families based on whether the child was born on an even or odd date. Additional evidence consists of post-implementation reports from enrolled parents on their satisfaction with the program and estimates of the program’s return on investment and cost-savings potential based on results from the randomized trial.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Guiding program development through focus groups: Beginning in 2006, Dr. Dodge held a series of focus groups with key stakeholders, including parent-led organizations, medical groups (primary care doctors, pediatricians, and obstetricians), and community agencies. These focus groups provided valuable input and feedback on how the program should work and hence served as the basis for its development.
  • Creating marketing materials: By 2008, it became clear that DFI would launch a universal program to offer nurse home visits to all Durham County families with newborns. In preparation for that launch, a team of individuals worked over a 6-month period to develop the program name (Durham Connects) and related marketing materials, including a logo and brochures.
  • Developing, maintaining EMR and referral database: Over the same time period, staff developed a program-specific EMR database and gathered the requisite information to create Agency Finder, a separate database using commercially available software. The two systems were set up so that they linked with each other electronically. Existing staff, including the nurses, now maintain the database.
  • Establishing community advisory boards: Program leaders established two community advisory councils that oversee and support the program on an ongoing basis. The first, known as the Leadership Council, includes three key stakeholders (parent groups, clinicians, community agencies), along with representatives from local universities and corporations. This group provides advice and guidance on an ongoing basis to program leaders. The second group, known as the Community Advisory Board, consists of representatives of provider organizations and community agencies that get regular referrals from Durham Connects nurses. Its goal is to identify and address quality problems and service capacity issues in a timely manner.
  • Developing materials to support nurses: Dr. Karen O’Donnell at the Center for Child and Family Health took charge of developing the aforementioned Family Support Matrix and other manuals, scripts, and tools used by the nurses on a regular basis. These materials include a 400-page operations manual that provides detailed information on all aspects of the program, along with an abbreviated 30-page version that focuses primarily on the home visit.
  • Hiring and training nurses: Each nurse goes through full-time training for a period of 4 to 6 weeks. The first few weeks focus on the home visit, including conducting motivational interviewing and using and scoring the assessment tool. During the second half of training, nurses observe others as they conduct visits and then begin to conduct visits on their own under the observation of a more senior nurse. Nurses must be certified by Dr. O’Donnell before they can conduct home visits on their own. As an ongoing source of support, nurses receive regular reports showing their adherence to program protocols and their reliability in using the assessment tool.
  • Pilot testing in advance of randomized trial: Beginning in 2008, the program underwent approximately a year of pilot testing to identify what did and did not work well. This testing surfaced the need for several changes, such as conducting the enrollment visit as a face-to-face meeting in the hospital (rather than over the phone) and using odd and even dates on the calendar as the mechanism for randomization (rather than attempting to create two groups of similar neighborhoods that proved quite challenging).
  • Conducting randomized trial, continuing program on ongoing basis: As noted, the trial ran over an 18-month period, from July 2009 through the end of 2010. Based on its success, program leaders decided to continue the program and now offer it to all Durham County residents who have a baby at either of the two hospitals in the county that perform deliveries.
  • Expanding to rural counties: Based on the program’s success, the State of North Carolina contracted with Durham Connects leaders to oversee replication of the program in four rural counties in northeastern North Carolina, using funds from North Carolina’s grant from the Federal Race to the Top Early Learning Challenge. Under the current plan, responsibility for the program (known as Northeast Connects) will transition to a local entity (e.g., hospital, university, nonprofit organization) within a year or two.

Resources Used and Skills Needed

  • Staffing: The program requires 9 to 10 full-time public health nurses to cover the approximately 3,200 births in Durham County each year. With 10 nurses, staffing levels are adequate to cover vacation and sick days. (At one point, program leaders considered using social workers, but ultimately decided that nurses would be more effective.) Initially, program leaders required that all nurses have a bachelor’s degree, but now accept strong candidates with an associate’s degree. The best candidates have some prior public health experience.
  • Costs: Durham Connects costs roughly $700 per enrolled family, which means the program would cost $2,240,000 to serve the families of all 3,200 newborns each year in Durham County. The primary cost consists of compensation to the nurses, who earn an average of $60,000 a year plus benefits. Additional costs include support staff, supplies, travel, and administrative expenses (e.g., rent, information technology, phone).8
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Funding Sources

Duke Endowment; Eunice Kennedy Shriver National Institute of Child Health and Human Development; Oak Foundation; Pew Center on the States; Durham County Commissioners
The Duke Endowment provides the vast majority of funding for ongoing operations, with the Durham County Commissioners, the Oak Foundation, and other local foundations providing some additional support. In addition, the North Carolina Medicaid program provides partial reimbursement for the home visits completed with Medicaid-enrolled families.

The Pew Center on the States and the Eunice Kennedy Shriver National Institute of Child Health and Human Development provided funding to support an independent evaluation of the program.end fs

Tools and Other Resources

The following resources provide background on community approaches to using nurse home visits to prevent child maltreatment:
  • Daro D, Dodge KA. Creating community responsibility for child protection: possibilities and challenges.  Future Child. 2009;19(2):67-93. [PubMed]
  • Dodge KA, Coleman DL, editors. Preventing child maltreatment: community approaches. New York: Guilford Press; 2009.
  • Rosanbalm KD, Dodge KA, Murphy R, et al. Evaluation of a collaborative community-based child maltreatment prevention initiative. Protecting Children. 2010;25(4):8-23.

Additional materials related to the program can be obtained by contacting Dr. Benjamin Goodman, Director of Evaluation for Durham Connects. These materials include the Family Support Matrix and the program’s home visiting manual, which details visiting procedures and provides protocols, scripts, and other tools to assist nurses in adhering to them.

Adoption Considerations

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Getting Started with This Innovation

  • Lay groundwork with local community: Program leaders believe that the successful launch of this kind of program requires at least a year’s worth of community-building effort. This process involves multiple meetings to elicit input and address the concerns of key stakeholders, including hospitals and community-based agencies serving families with young children. In hindsight, Durham Connects leaders believe they needed to spend more time convincing hospitals and physicians to engage in and take ownership of this program.
  • Invest in training and support for nurses: As noted, Durham Connects requires that nurses go through a rigorous training program before allowing them to conduct home visits on their own, and then provides ongoing performance feedback and support to those that need additional help.
  • Consider face-to-face meetings to introduce program: While multiple strategies can be employed to introduce the program and enroll families, program leaders believe that face-to-face meetings in the hospital are most effective.
  • Plan for sustainability from beginning: As noted, the program relies heavily on grant funding to sustain its operations. In hindsight, its leaders believe they should have focused on securing long-term, sustainable funding streams earlier. Potential sources include public and private insurers and health plans, hospitals, governments at all levels (local, State, and Federal), foundations, and community-based organizations. The leaders of State Medicaid programs should be particularly receptive to supporting this type of program, as the significant reduction in emergency medical episodes (both emergency department visits and hospitalizations) has the potential to generate substantial cost savings. In addition, the leaders of organizations focused on related issues (e.g., infant mortality, school readiness, maternal health and pregnancy prevention, and depression and mental health screening) might be interested in providing support.
  • Expect tough sell with private stakeholders: Convincing private-sector organizations to support the program may prove difficult, as the leaders of these organizations are often unaccustomed to supporting programs that serve everyone. Rather, they tend to believe in dedicating scarce resources only to those most likely to benefit. As described earlier, Durham Connects does provide greater levels of support to those most at risk, but offers an assessment and some level of support to every family with a newborn in the county.

Sustaining This Innovation

  • Create and maintain community advisory boards: The two advisory boards serve as an effective vehicle for eliciting community concerns on an ongoing basis and keeping key stakeholders engaged over time.
  • Use nurses for inhospital visit: During the initial trial and the first few years after it ended, Durham Connects used paraprofessionals to conduct the inhospital visit. While enrollment rates were high (80 percent) during the trial, they dropped off somewhat after it ended, as the allure of participating in a randomized trial ended. Program leaders subsequently decided to have public health nurses conduct the inhospital visits, believing that they could talk more confidently and convincingly about the program’s benefits and better connect with new mothers. Enrollment rates are increasing now that the nurses have taken on this responsibility.
  • Track and publicize program outcomes to maintain funding: Maintaining sustainable sources of funding will be more likely if leaders regularly track and publicize data on the program’s impact on key metrics of concern to community leaders, such as infant mortality, parenting skills, use of health care resources, pregnancy spacing, access to birth control, and breastfeeding. The goal should be to establish the approach as an evidence-based program. To that end, Durham Connects leaders plan to track the newborns enrolled in the initial randomized, controlled trial through the age of 5.
  • Continue investing in and supporting nurses: Because it takes significant time and effort to get nurses “up to speed,” it makes sense for program leaders to pay nurses competitive salaries and invest in programs to support them over time. High turnover can be expensive and makes it difficult for the program to serve everyone in a high-quality manner.

Use By Other Organizations

As noted, plans are in place to use the same model in four other North Carolina counties. In addition, two counties in other States have similar programs, including Los Angeles County’s First 5 LA program (http://www.first5la.org), and Kent County, Ohio’s Welcome Home Baby program (http://www.firststepskent.org/programs/welcome-home-baby). The State of Massachusetts plans to launch a similar program in a few counties and then roll it out across the State over time.

More Information

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Contact the Innovator

Benjamin Goodman, PhD
Research Scientist
Center for Child and Family Policy
Duke University
Box 90539
Durham, NC 27708-0539
(919) 668-4126
E-mail: ben.goodman@duke.edu

Innovator Disclosures

In addition to the funders listed in the Funding Sources section, Dr. Goodman reported receiving reimbursement for expenses for travel to professional conferences where he gives presentations on Durham Connects; all such reimbursement requests are approved by Duke University.

References/Related Articles

Dodge, KA, Goodman WB, Murphy RA, et al. Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. Am J Public Health. 2013;e1-8. [PubMed]

Dodge, KA, Goodman WB, Murphy RA, et al. Randomized controlled trial of universal postnatal nurse home visiting: impact on emergency care. Pediatrics. 2013;132:s140-6. [PubMed]

Zolotor AJ. Preventing child maltreatment in North Carolina. NC Med J. 2010;71(6):553-5. [PubMed]

Dodge KA, Goodman WB, Murphy R, et al. Toward population impact from home visiting. Zero Three. 2013;33(3):17-23. [PubMed]

Alonso-Marsden S, Dodge KA, O’Donnell KJ, et al. Family risk as a predictor of initial engagement and follow-through in a universal nurse home visiting program to prevent child maltreatment. Child Abuse Negl. 2013;37(8):555-65. [PubMed]

More information on Durham Connects is available at: www.durhamconnects.org.

Footnotes

1 U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2009. Washington, DC: U.S. Government Printing Office, 2010. Available at: http://www.acf.hhs.gov/programs/cb/stats_research/index.htm#can.
2 Duncan DF, Kum HC, Flair KA, et al. Management assistance for Child Welfare, Work First, and Food and Nutrition Services in North Carolina. 2013. University of North Carolina at Chapel Hill Jordan Institute for Families Web site. Available at: http://ssw.unc.edu/ma.
3 Hussey JM, Chang JJ, Kotch JB. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics. 2006;118(3):933-42. [PubMed]
4 American Academy of Pediatrics, Stirling J Jr, Committee on Child Abuse and Neglect and Section on Adoption and Foster Care, et al. Understanding the behavioral and emotional consequences of child abuse. Pediatrics. 2008;122(3):667-73. [PubMed] [Published correction appears in Pediatrics. 2009;123(1):197.]
5 North Carolina Child Fatality Prevention Team. Annual report, 2007. Raleigh, NC: Office of the Chief Medical Examiner. North Carolina Department of Health and Human Services; 2009.
6 Wang C, Holton J. Total estimated cost of child abuse and neglect in the United States. Chicago: Prevent Child Abuse America; 2007.
7 Dodge, KA, Goodman WB, Murphy RA, et al. Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. Am J Public Health. 2013; e1-8. [PubMed]
8 Dodge KA, Goodman WB, Murphy R, et al. Toward population impact from home visiting. Zero Three. 2013;33(3):17-23. [PubMed]
9 O’Donnell K, Goodman WB, Murphy R, et al. Assessment of family risk for infant maltreatment. Unpublished manual. Durham, NC: Duke University.
10 Dodge, KA, Goodman WB, Murphy RA, et al. Randomized controlled trial of universal postnatal nurse home visiting: impact on emergency care. Pediatrics. 2013;132:s140-6. [PubMed]
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Original publication: March 26, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.